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ICD-10-CM T43.026A, Underdosing of tetracyclic antidepressants, initial encounter | No Prior Auth

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`T43.026A`, Underdosing of tetracyclic antidepressants, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical necessity for each test must be documented in the patient's medical record as required by LCD L35006.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include patient identification and dates of service.
Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

When E/M services are reported with allergy testing, medical documentation of the separately identifiable E/M service must be present in the medical record and modifier -25 must be used.

Part B providers must indicate the actual number of tests (one unit per antigen/test) in Box 24G of Form CMS-1500 (paper) or in the service field on EMC claims; the number of tests must also be shown on the claim for MPFSDB payment.

Key Coverage Criteria

Urine drug testing (UDT) and drugs-of-abuse testing are covered when reasonable and necessary per LCD L35006 and ordered on an individual patient basis by the treating clinician with medical-record documentation of medical necessity.
Patients with a documented diagnosis consistent with substance use disorder (SUD) may qualify for an exception to the standard presumptive UDT annual limits.
Allergy testing is covered when the patient has clinically significant allergic symptoms and conservative therapy has failed.
Allergy testing includes performance, evaluation, and reading of cutaneous and mucous membrane tests together with physician history (including immunologic history), physical examination, antigen selection, and interpretation of results.
Standard skin testing is the preferred method when allergy testing is necessary.
When a percutaneous or intracutaneous single test (CPT 95004 or 95024) and sequential/incremental tests (CPT 95017, 95018, 95027) are performed the same day, both code types may be reported only if they are for different allergens or for different dilutions of the same allergen.

6 Active Policies

WPS-J5-L36402, Allergy Testing

J5

A57473, Billing and Coding: Allergy Testing

J5

WPS-J8-L36402, Allergy Testing

J8

NOVITAS-JH-L35006, Controlled Substance Monitoring and Drugs of Abuse Testing

JH

NOVITAS-JL-L35006, Controlled Substance Monitoring and Drugs of Abuse Testing

JL

A56645, Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing

JL

Related Codes

T39.012D(6 policies)T39.014A(6 policies)T39.011D(6 policies)T39.012A(6 policies)T39.013A(6 policies)T39.013D(6 policies)T39.011A(6 policies)T39.014D(6 policies)

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